MEDICAL DECISION-MAKING: Content of Service

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Transcript of MEDICAL DECISION-MAKING: Content of Service

ESTABLISHED PROBLEM-STABLE or IMPROVINGPresenting problem that is not known to the physician (New) that DOES require diagnostic workup.Presenting problem that is not familiar to the performing physician, and that does not require diagnostic workup.ESTABLISHED PROBLEM -WORSENINGPresenting problem that is known to the physician (established) and worsening.Presenting problem that is known to the physician (established) and stable or improving. and/orMEDICAL DECISION MAKINGNEW PROBLEM with WORKUPNEW PROBLEM without WORKUPMINIMALHIGH...the condition, disease, illness, injury, complaint or other medical reason for which the patient has presented to the healthcare facility for the E/M service....specific tests used to determine the internal function, status, structures, and/or pathology occurring within the patient.Management Options SelectedMODERATEof COMPLICATION,Review of Diagnostic Test Resultsand/orIndependent Visualization of Image, Tracing, or ScanOrdering Diagnostic DataObtain Old RecordsObtain Additional HistoryDiscussion of Diagnostic Results with Physician who Performed Diagnostic TestAMOUNT of DATA to be REVIEWEDCOMPLEXITY of DATA to be REVIEWEDMINIMALMINIMALLOWLOWMODERATEMODERATEHIGHHIGHLOWPresenting Problem...Diagnostic Procedures OrderedMANAGEMENT OPTIONSNUMBER of DIAGNOSESLEVEL of RISKCO-MORBIDITYor MORTALITY...documentation of any existing or initiated method of treatment, care, or management of the presenting problem.All material taken from MEDICAL CODING EVALUATION AND MANAGEMENT, Kate Gabriel-Jones; Larry A. Bohn, Pearson 2014